Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southfield Village during CMS and state inspections, most recent first.
The facility had dusty fans, walls, ceiling, and light fixtures in the food prep area, along with yellowish-brown matter on the wall behind the stove and griddle. In addition, a resident’s breakfast tray was left out while the resident slept, then reheated and served by a CNA without checking the food temperature after microwaving. The DOD stated the tray was not remade and that nursing staff should have taken the temperature of the reheated omelette.
Unlocked Medication and Treatment Carts: Medication and treatment carts on 100, 200, and 300 Halls were observed unlocked and unattended during multiple observations. RN 5, RN 6, LPN 3, and the Executive Director each acknowledged the carts were not locked when they should have been. The treatment carts contained prescribed topical creams and gels, antifungal cream, and antifungal powder for residents, and the facility policy stated all drugs and biologicals must be stored in locked compartments.
Meals were not consistently served at a palatable temperature on the 100 Hall. Two residents reported receiving meals that were often cold or lukewarm, including meals eaten in-room and in the common area. During meal observation, a grilled cheese sandwich on the last tray measured 107 F, and the DOD stated he was unsure of the correct serving temperature, despite identifying 135 F as the hot food holding temperature.
Infection control practices were not followed during Foley care and wound treatment for a resident on EBP for pressure injuries and a Foley catheter. A CNA emptied the urinary drainage bag without the required PPE, the bag was later observed on the floor under the resident’s chair, and an RN stated it should not have been there. During wound care, an WN/IPN did not change gloves or use hand hygiene between dirty and clean tasks, and also provided catheter care without changing gloves first.
Failure to Notify Physician of Elevated Blood Pressures: A resident with HTN had an order for hydralazine with parameters requiring MD notification for elevated BP readings. The MAR showed two BP readings above the ordered limits, but the physician was not notified. The DON later stated the MD should have been notified and that the facility did not have a policy for following physician orders or the plan of care.
Failure to Assist Resident With Meals: A resident with cerebral infarction, dementia, and dysphagia had severe cognitive impairment and required supervision and touch assist for eating. Staff did not provide cueing or hands-on help when the resident dumped soup onto her plate, said the chili was too hot, or asked for coffee, and no substitute food was offered. During another meal, the resident’s cereal spilled in her lap and onto the floor, staff did not assist her while she tried to eat from her lap, and the tray was removed even after she said she was not done.
A resident with edema and multiple chronic conditions was ordered to wear Tubigrips to both lower extremities, but was repeatedly observed without them while the TAR still showed the task as completed and there was no refusal documented. Another resident with COPD, chronic pulmonary edema, hospice services, and risk for pressure injury was ordered to have heels floated at all times except during care, but was repeatedly observed with heels resting on the mattress while the TAR also showed the task as completed. The RNC stated the tasks should not have been marked completed when they had not been done.
A WN/IPN failed to follow infection control practices during wound care and catheter care for a resident with multiple wounds, including the buttocks, coccyx, thighs, toes, and heel. She removed dressings, assessed and treated wounds, and provided catheter care without changing gloves or using hand sanitizer at required points, and she reused the same cotton swab and medicated pad across wounds. The DON stated gloves should be changed and hand sanitizer used after dirty dressing removal, after wound treatment, and before clean bandage application, while facility checklists and policies indicated hand hygiene and glove use were required.
The facility failed to maintain sanitary conditions in the kitchen, with a container of pickles stored without a secure lid in the walk-in cooler and dirty utensils found in the clean utensils drawer. The Director of Food Services acknowledged these issues, which were contrary to the facility's policy requiring weekly spot checks for compliance.
The facility failed to notify physicians of elevated blood glucose levels for two residents with type 2 diabetes, as required by physician orders. Resident 7 had multiple instances of elevated levels without documentation of physician notification, confirmed by the DON. Similarly, Resident 3's elevated levels were not reported, as indicated by the MAR and interviews with the DON and an LPN. The facility's policy required timely reporting of critical test results, which was not followed.
The facility failed to provide a Bed Hold Policy to a resident transferred to the hospital with conditions including Alzheimer's and COPD. Despite issuing a Notice of Transfer/Discharge, there was no documentation of the Bed Hold Policy being given. An employee confirmed its absence in the chart, and the MDS Nurse later provided the policy, but the facility lacked guidance on when to issue it.
The facility failed to conduct quarterly Care Plan meetings with two residents and/or their representatives. One resident, with intact cognition and multiple health issues, reported not being invited to meetings, and her records lacked documentation of such meetings. Another resident, with severe cognitive impairment, also had no documented Care Plan meetings. The Social Services Director confirmed that meetings should have occurred, as per the facility's policy.
The facility failed to follow infection control practices in two incidents. A housekeeper cleaned a resident's room under contact precautions for Clostridium difficile without wearing a gown, misunderstanding the signage. Additionally, a CNA did not change gloves or use a clean washcloth during catheter care for a resident with a Foley catheter. Both staff members later acknowledged their errors.
Unsanitary Kitchen Conditions and Unsafe Food Temperature Monitoring
Penalty
Summary
The facility failed to provide a clean and sanitary environment for food preparation. During a kitchen observation, three fans in the food preparation area were dusty, the walls, ceiling, and light fixtures were dusty, and the wall behind the stove and griddle had yellowish-brown matter on it. During interview, the Dietary Manager stated there should not have been dust on the fans, walls, ceiling, or light fixtures, and the wall behind the griddle should have been clean. The Dietary Manager later stated there was not a policy for cleaning the kitchen but provided the cleaning schedule staff followed. The facility also failed to ensure meals served to a resident were within safe serving temperatures. Resident 11 was observed sleeping while breakfast trays were delivered to the unit and left on a table in the common area. CNA 7 later took the tray, reheated the resident’s food in the microwave, and served it without taking the temperature of the food after reheating. On another observation, CNA 7 again delivered the resident’s breakfast tray after it had been heated in the microwave without checking the food temperature. The Director of Dining stated the kitchen had not remade the tray, did not know how long high-risk food could remain out before needing to be remade, and stated nursing staff should have taken the temperature of the reheated omelette.
Unlocked Medication and Treatment Carts
Penalty
Summary
Drugs and biologicals were not kept in locked compartments as required, based on observations of medication and treatment carts on 100, 200, and 300 Halls. On 1/9/2026, the medication cart on 100 Hall was observed unlocked and unattended from 8:52 A.M. until 8:57 A.M.; RN 5 stated the cart was not locked but should have been locked. On 1/9/2026, the medication cart on 300 Hall was observed unlocked and unattended from 8:58 A.M. until 9:03 A.M.; RN 6 stated she had been responsible for the cart and it was not locked while she was in a resident's room and unable to see it. The treatment cart on 300 Hall was also observed unlocked and unattended from 9:05 A.M. until 9:07 A.M. and contained prescribed topical creams and gels, antifungal cream, and antifungal powder for residents; RN 6 stated the cart had not been locked but should have been locked. On 1/11/2026, the medication cart on 200 Hall was observed unlocked and unattended at 4:25 P.M., and LPN 3 stated it had not been locked but should have been locked. The treatment cart on 200 Hall was then observed unlocked and unattended from 4:29 P.M. until 5:50 P.M. and contained prescribed topical creams and gels, antifungal cream, and antifungal powder for residents; the Executive Director stated the treatment cart should not have been left unlocked. The DON provided the facility's Medication Storage Policy, dated 4/9/2019, which stated that all drugs and biologicals will be stored in locked compartments, including medication carts, cabinets, drawers, refrigerators, and medication rooms.
Meals Served at Improper Temperature
Penalty
Summary
The facility failed to provide meals at a palatable temperature for the 100 Hall meal trays. During interviews, one resident who ate all meals in his room stated that most of his meals were served cold and that he could ask for reheating, but then had to wait to eat and this occurred with every meal. Another resident who ate in the 100 Hall common area stated that most of her meals were served lukewarm or cold and that she had stopped requesting reheating. During observation of the 100 Hall lunch meal service, the meal cart arrived at 12:02 P.M., and at 12:15 P.M. the DOD took the temperature of the grilled cheese sandwich on the last meal tray for the 100 Hall. The grilled cheese measured 107 F. During interview, the DOD stated he was not sure what temperature the grilled cheese should have been when served. The DOD identified the hot food holding temperature as 135 F, and the facility policy referenced maintaining proper hot and cold holding temperatures and using the FDA Food Code for food temperatures.
Infection Control Failures During Foley Care and Wound Treatment
Penalty
Summary
The facility failed to follow infection prevention practices during Foley catheter care, wound care, and handling of a urinary drainage bag for a resident who had Enhanced Barrier Precautions in place. Resident 6 had diagnoses including spinal stenosis, anemia, an unstageable pressure ulcer on the buttocks, and fractured vertebrae. The resident’s physician order required Enhanced Barrier Precautions for high-risk activities related to the Foley catheter and pressure wounds, and the care plan also identified the need for Enhanced Barrier Precautions because of pressure injuries and the Foley catheter. During observation, a CNA emptied the resident’s Foley urinary drainage bag without wearing the PPE required by the resident’s Enhanced Barrier Precautions sign. The CNA stated she did not believe PPE was needed for emptying the drainage bag, then later acknowledged that PPE should have been worn. In a separate observation, the resident’s urinary drainage bag was seen lying on the floor under the resident’s chair while the resident was seated in the common area eating breakfast. An RN stated the bag should not have been on the floor, and the DON stated the facility did not have a policy regarding urinary drainage bags but followed the Standards of Care. During wound care, the WN/IPN removed dressings from multiple wounds, inserted a finger into the buttocks wound to assess channeling, measured wounds, cleansed wounds, applied treatments, packed the wound, and applied clean bandages without changing gloves or using hand sanitizer between dirty and clean tasks. The WN/IPN also provided catheter care without changing gloves or using hand sanitizer after removing dirty dressings and before starting catheter care. The WN/IPN stated she did not need to change gloves or use hand sanitizer during these steps, while the DON stated gloves should be changed and hand sanitizer used after removing a dirty dressing, after completing wound treatment, and before applying a clean bandage.
Failure to Notify Physician of Elevated Blood Pressures
Penalty
Summary
The facility failed to follow physician orders and notify the physician of elevated blood pressures for Resident 2, who had a diagnosis of essential hypertension and an order for hydralazine 10 mg by mouth every 8 hours. The order required the medication to be held if the resident's systolic blood pressure was less than 120 mmHg and required physician notification if systolic blood pressure was greater than 150 mmHg, diastolic blood pressure was greater than 90 mmHg, or diastolic blood pressure was less than 60 mmHg. The MAR showed blood pressure readings of 165/73 on 1/1/2026 and 193/99 on 1/5/2026, both of which met the criteria for physician notification, but the physician was not notified on either occasion. The DON later stated that the physician should have been notified of the elevated blood pressures and that the facility did not have a policy for following physician orders or the plan of care as it is considered the standard of care.
Failure to Assist Resident With Meals
Penalty
Summary
The facility failed to provide assistance and cueing with eating for a resident who was unable to independently manage meals. The resident had diagnoses including cerebral infarction with left-sided hemiplegia/hemiparesis, dementia, and dysphagia. A quarterly MDS assessment indicated severe cognitive impairment and that the resident required supervision and/or touch assist for eating needs. The care plan, initiated for risk of weight fluctuations and nutrition problems, directed that the resident eat in the assist dining room for supervision and cueing. During lunch observation, the resident ate only one bite of chili soup and then began dumping spoonfuls of soup onto her plate, but staff did not offer assistance or cueing to encourage her to eat. When the resident stated the chili was too hot and asked for coffee, the CNA provided coffee but did not offer a substitute for the soup. During a breakfast observation the next day, the resident’s cereal had spilled in her lap and onto the floor, and staff made no attempt to assist her while she tried to eat from her lap. When asked if she was done, the resident said no, but the CNA removed the tray, took the resident to her room to change her top, and returned her to the table without offering any other food.
Failure to Follow Orders for Edema Support and Heel Floating
Penalty
Summary
The facility failed to follow physician orders for 2 residents reviewed for vascular needs and pressure relief. One resident with stage 3 chronic kidney disease, a left femur fracture, atrial fibrillation, moderate cognitive impairment, and edema was ordered to have Tubigrips applied to both lower extremities in the morning and removed at bedtime. The resident was observed on multiple occasions without the Tubigrips in place, and the resident stated the facility had not provided leg wraps for the edema in either lower leg or foot. Although the January TAR documented the Tubigrips as worn, the resident’s record did not contain documentation that the resident had refused the wraps, and the RNC stated the TAR should not have been marked completed because the task had not been done. Another resident with COPD, anxiety disorder, chronic pulmonary edema, dysphagia, moderate cognitive impairment, hospice services, and risk for pressure injury was ordered to have the heels floated at all times except during care. The resident was observed lying in bed with both heels directly on the mattress on several occasions, and a hospice CNA stated the heels were not floated but should have been. The January TAR documented the heels as floated on those dates even though observations showed they were not elevated, and there was no documentation that the resident refused heel floating. The RNC stated it was unclear why the heels had not been floated and that tasks should not have been marked completed when they had not been completed.
Infection Control Lapses During Wound and Catheter Care
Penalty
Summary
The facility failed to ensure staff providing wound care and directing wound and infection control measures were competent. During observation of wound care for a resident with wounds to the right buttocks, coccyx, thighs, toes, and left heel, the Wound Nurse/Infection Preventionist Nurse removed dressings, inserted her index finger into the buttocks wound to assess channeling, measured wounds with a cotton swab, cleaned the wounds, applied medicated pads and ointment, packed the buttocks wound, and covered the wounds with clean bandages. She also provided urinary catheter care during the same encounter. Throughout these tasks, she did not change gloves or use hand sanitizer after removing dirty dressings, before applying treatments, before applying clean bandages, or before catheter care. After catheter care, the Wound Nurse/Infection Preventionist Nurse changed gloves and used hand sanitizer, then continued wound care to the resident's thigh wounds, toe wounds, and left heel. For the thigh wounds, she used the same medicated pad to wipe both wounds and the same cotton swab to measure both wounds. For the toe wounds, she did not change gloves or use hand sanitizer after removing the bandages and before cleaning, measuring, or applying a clean bandage. For the left heel wound, she again did not use hand sanitizer or change gloves after removing the dressing and before starting treatment or applying a clean bandage. During interview, the nurse stated she had been changing dressings for over 20 years and did not need to change gloves or use hand sanitizer after removing dirty dressings, after applying treatments, or before applying clean bandages, although she acknowledged she should have changed gloves and used hand sanitizer before catheter care. The DON stated gloves should be changed and hand sanitizer used after removing a dirty dressing, after completing wound treatment, and before applying a clean bandage. Facility checklists and policies also indicated hand hygiene and glove use were required for catheter care and wound care.
Sanitation Deficiencies in Kitchen Storage and Utensil Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, specifically in the storage and handling of food and utensils. During an initial kitchen tour, it was observed that a container of pickles in the walk-in cooler was stored without a secure lid, leaving it open to air. The Director of Food Services acknowledged that the lid should have been secured. In a follow-up kitchen tour, it was found that a metal scoop and a pair of metal tongs with dried food on them were stored in the clean utensils drawer, which also contained dried food and other debris at the bottom. The Director of Food Services confirmed that utensils should be clean before being placed in the drawers and that the utensil drawer should have been cleaned. The facility's policy required weekly spot checks of refrigerators for compliance, but these deficiencies were still present.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of elevated blood glucose levels for two residents with type 2 diabetes, leading to a deficiency. For Resident 7, the physician's order required notification if blood glucose levels were below 70 or above 200 mg/dL. However, the facility did not document any notification to the physician for multiple instances of elevated blood glucose levels ranging from 210 mg/dL to 319 mg/dL over the months of August, September, and October 2024. The Director of Nursing (DON) confirmed that the electronic medication administration record (EMAR) lacked documentation of physician notification, which should have been recorded. Similarly, for Resident 3, the physician's order required notification for blood glucose levels less than 70 or greater than 200 mg/dL. The Medication Administration Record (MAR) showed elevated blood glucose levels on several occasions in September and October 2024, with no documentation of physician notification. Interviews with the DON and LPN 6 revealed that such notifications should have been documented in the nursing progress notes or associated with the order in the MAR. The facility's policy on blood glucose monitoring required timely reporting of critical test results to the physician, which was not adhered to in these cases.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy to a resident when they were admitted to the hospital. This deficiency was identified during a review of Resident 4's records, who had diagnoses including Alzheimer's Disease, chronic obstructive pulmonary disease, and atrial fibrillation. On 9/7/2024, Resident 4 experienced shortness of breath and confusion, leading to a hospital transfer for suspected pneumonia. Although the Notice of Transfer/Discharge was documented, there was no evidence that the Bed Hold Policy was provided to the resident. An interview with Employee 6 confirmed the absence of the Bed Hold Policy in the resident's chart. The MDS Nurse later provided a copy of the policy that should have been given, but the facility lacked a policy indicating when this document should be provided.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct Care Plan meetings quarterly with residents and/or their representatives, as required. Resident 6, who has diagnoses including chronic obstructive pulmonary disease, hemiplegia, dysphagia, aphasia, vascular dementia, and emphysema, reported not being invited to Care Plan meetings. Her record showed no documentation of such meetings from November 2023 through May 2024, despite having an intact cognition and receiving a Quarterly Minimum Data Set (MDS) assessment in September 2024. The Social Services Director (SSD) confirmed that a Care Plan meeting should have occurred after her MDS assessment in January 2024. Similarly, Resident 7's representative could not recall being invited to a Care Planning meeting. Resident 7, who has severe cognitive impairment and diagnoses including type 2 diabetes mellitus, sick sinus syndrome, cardiomegaly, and adjustment disorder, also lacked documentation of Care Plan meetings between November 2023 and April 2024. The SSD acknowledged that a meeting should have been conducted during this period. The facility's policy, dated January 2024, mandates Care Plan meetings every three months or when there is a significant change in a resident's health status.
Infection Control Lapses in Isolation Room Cleaning and Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection control practices as observed in two separate incidents involving staff members. In the first incident, a housekeeper was observed cleaning the room of a resident on contact precautions due to Clostridium difficile without wearing a gown, as required. The housekeeper misunderstood the signage indicating contact precautions and did not recall receiving training on the differences between contact precautions and enhanced barrier precautions. The Assistant Director of Nursing (ADON) confirmed that the housekeeper should have donned a gown before entering the room. The resident in question had a positive Clostridium difficile result and was under specific isolation orders. In the second incident, a CNA was observed providing catheter care to a resident with an indwelling Foley catheter without changing gloves or using a clean washcloth between cleaning different areas. The CNA initially did not recognize any wrongdoing but later acknowledged the need to change gloves and use a clean washcloth. The facility's policies on isolation precautions and catheter care were reviewed, indicating the need for adherence to specific procedures to prevent infection transmission.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near South Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trailpoint Village | 2.7 mi | ★★★★★ | 19 | 0 |
| Brickyard Healthcare - Twelfth Street Care Center | 4.5 mi | ★★★★★ | 29 | 0 |
| Cardinal Nursing And Rehabilitation Center | 4.9 mi | ★★★★★ | 0 | 0 |
| Milton Home, The | 5.2 mi | ★★★★★ | 6 | 0 |
| Holy Cross Village At Notre Dame Inc | 6 mi | ★★★★★ | 20 | 0 |
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